Moral Distress in Family Health Strategy: experiences expressed by daily life
Moral Distress in Family Health Strategy:
experiences expressed by daily life*
Cecília Maria Lima Cardoso1, Maria Odete Pereira2, Danielle de Araújo Moreira3, Hanna Beatriz Bacelar Tibães4, Flávia Regina Souza Ramos5, Maria José Menezes Brito6
Sofrimento Moral na Estratégia de Saúde da Família: vivências desveladas no cotidiano Sufrimiento Moral en la Estrategia Salud de la Familia : las
experiencias expresan en la vida cotidiana
* Experience of Moral Distress in the Family Health Strategy: professionals’ vision. 2015, School of Nursing, University of Minas Gerais. 1 Centro Universitário de Sete Lagoas - UNIFEMM, Faculdade Ciências da Vida, Sete Lagoas, MG, Brazil.
2,3,4,6 Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
5 Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
DOI: http://dx.doi.org/10.1590/S0080-623420160000300013
ABSTRACT
Objective:Understanding theMoralSufferingexperiences expressedin the daily lifeof the FamilyHealth Strategy.
Method: his is a case study with a qualitative approach, conducted between August and October 2014 in a municipality of Minas Gerais. he sample was represented by 28 professionals of family health teams. Data were collected through interviews with semi--structured questionnaires, observation, projective technique and submitted to thematic content analysis.
Results: he results indicate that routine issues of the health care system lead professio-nals to experience a challenging practice in dealing with daily situations that contradict their ethical precepts and can compromise the quality of work, becoming triggers of Moral Distress.
Conclusion: Social vulnerabilities such as domestic violence, poor socioeconomic con-ditions and organizational weaknesses of the health system were the main triggers of Moral Distress. herefore, it is necessary to amplify this relection by workers of the Family Health Strategy, aiming to encourage the minimization of sufering experiences, considering their ethical values.
DESCRIPTORS
Family Health Strategy; Ethics; Moral damage.
Correspondence Addressed to: Cecília Maria Lima Cardoso
Avenida Marechal Castelo Branco, nº 2765, Bairro Santo Antônio
CEP 35701242, Sete Lagoas, MG, Brazil
cecilia.lima@unifemm.edu.br Received: 26/03/2015Approved: 14/11/2015 ORIGINAL ARTICLE
INTRODUCTION
Primary Health Care (PHC) is generally the irst con-tact of service users in relation to treatment plans based on rapport and continuity of care. his health care point is characterized by the development of highly complex clini-cal activities and longitudinal actions, which aim to ensure comprehensive care (1).
In Brazil, PHC is organized by the Family Health Strategy (ESF), which aims to produce a service based on care and management models that are geared to me-et the needs of service users, with an emphasis on health promotion and the prevention of illness. Consequently, it is based on family-centered health care that considers the environment in which people live and the space in which relationships are constructed (2).
he ESF is guided by four key attributes: access to ser-vices at irst contact; longitudinality; comprehensiveness; and coordination of care. hese factors are recognized as the structural axes of the health care process and they are associated with the quality, efectiveness and eiciency of its services (2-3)
.
hrough these assumptions, the actions of the ESF are intended to be conducted in a coordinated manner in con-junction with the services provided by the Health Care Ne-twork in order to respond to demands for service in an inte-grated manner. However, this requires eforts on the part of teams in order to act in a planned fashion and in accordance with the determinants of health to provide better living con-ditions for individuals, families and communities (4).
he ESF has contributed towards the reorganization of the health care model through the adoption of new mo-des of behavior by both professionals and service users (5). However, professionals often deal with situations that limit and hinder the efectiveness of the principles of PHC and this can result in members of health teams sufering from moral distress (MD).
Moral distress can be understood as pain or distress that afects the mind, body or interpersonal relationships in the workplace, in response to a situation in which a profes-sional recognizes their moral responsibility in a given situ-ation and has to make a judgment about the right conduct to be taken. However, the professional is unable to put that decision into practice due to service constraints, thereby provoking MD (6).
he aspects that trigger MD are associated with dii-culties in daily work, such as service organization and or-ganizational policies, which inluence the ability to exercise power, and can result in low levels of professional auto-nomy, restrictions on time and resources, and high levels of responsibility (7).
Health workers develop MD when they have to make diicult choices between following the rules and following their conscience. Consequently, MD triggers traditional symptoms of negative stress that occur due to situations in-volving ethical dimensions, in which the professional feels that they are unable to guarantee all their personal interests and values (8).
MD can be also described as a gap between the beliefs of an individual and their actions, which results in psycho-logical distress caused by painful feelings (9-10). hus, MD has implications for the lives of health workers in personal terms, which are represented by emotional and physical symptoms, and also in professional terms, which are related to job satisfaction and even the abandonment of the pro-fession (11).
It is worth noting the lack of studies on this topic, es-pecially in terms of PHC, which demonstrates the need for studies that explore the experiences of MD in the everyday life of professionals working within the Family Health Strategy in greater depth and from an interdisciplinary perspective.
Given the above, the objective of this study was to un-derstand the experiences of moral distress expressed in the daily lives of people working within the Family Health Strategy
METHODS
his study used a qualitative approach and the research method was that of a case study.
Qualitative research makes it possible to immerse one-self more deeply in relationships, processes and phenome-na which correspond to the universe of meanings, feelings, beliefs, values, attitudes and aspirations (12). Qualitative re-search aims to capture the diferent meanings of lived ex-periences; in this speciic case aiding the understanding of individuals working in the context of the ESF.
Case studies consist of a research strategy that studies events within the context of real life; they are considered to be the most appropriate design for investigating contem-porary cases, within their real context, where the boundary between these are not clearly deined (13).
his study was conducted between August and Octo-ber 2014 at four Family Health Teams in a municipality located in the interior of the state of Minas Gerais, Brazil. he following were used to collect data: observation; semi--structured interviews; and a projective technique using a cartoon entitled “Moral Distress”. he strategy was develo-ped by the following research centers: PRAXIS - work, ci-tizenship, health and nursing - (PEN/UFSC) at the Nur-sing School of the Federal University of Santa Catarina; he Center for Studies and Research in Nursing/Health (NEPS) at the Nursing School of the Federal University of Rio Grande (FURG); and the Center for Research in Nursing Administration (NUPAE) at the Nursing School of the Federal University of Minas Gerais (UFMG) (Fi-gure 1).
Moral Distress in Family Health Strategy: experiences expressed by daily life he use of this technique was intended to encourage awareness about the theme and to facilitate the partici-pants’ access to unconscious content, as well as creating op-portunities for them to express their subjectivities (14).
Figure 1 -Florianópolis, 2013.
he research participants were doctors, nurses, nursing technicians and community health workers (ACS’s), totaling 28 professionals, of which three were doctors, four were nur-ses, three were nursing technicians and 18 were ACS’s.
As an inclusion criterion, it was established that the professionals had to have worked in a municipal ESF for a minimum of one year. It was felt that this period of ex-perience would allow professionals to establish closer and more meaningful relationships in the context of the ESF and also greater familiarity with the routines and standards of the services provided.
Laurence Bardin’s content analysis technique, which “seeks to know what is addressed behind the words that are used”, was used for the data analysis (15). he categories emerged after the use of the central research question and the interpretation of Figure 1. he interviews were trans-cribed in full and analyzed according to the following pha-ses: pre-analysis; exploration of the material; treatment of the results; and inference and interpretation (15).
In the development of this study the authors followed the Brazilian rules and guidelines for human research as set out in Resolution CNS 466/2012. he study was approved by the Ethics Committee of the Federal University of Minas Gerais, as per report No. 749.142, and by the municipality that was the setting for this study, by letter of consent.
All the participants were informed about the objectives of the study and agreed to sign a consent form.
To ensure the anonymity of the participants it was de-cided to use codes in the presentation of the results, which were as follows: nurse (E); doctor (M), nursing technician (TE) and community health worker (ACS), followed by numbering according to the sequence of the interviews. For example: the irst nurse interviewed (E1); the third doctor interviewed (M3).
RESULTS
To understand the experience of MD in the daily lives of professionals working within the Family Health Strate-gy, the authors identiied the category “experiences of mo-ral distress in health practices within the context of the Fa-mily Health Strategy”, based on the analysis of situations that were narrated through the use of the cartoon and the content of the interviews.
he interviews that were conducted made it possible to identify everyday situations encountered by members of the Family Health Team which compromised the quality of their work and which triggered symptoms of MD such as: diiculty in meeting demands that arise in the work-place; infrastructure-related issues (materials, Health Care Network and multidisciplinary team); and requirements imposed on individuals by the ESF.
“ExpEriEncEsofmoraldistrEssinhEalthpracticEs withinthEcontExtofthE family hEalth stratEgy”
he experiences of MD identiied by the participants of this study were related to the social vulnerabilities that service users of the health unit are exposed to and the we-aknesses of the health system encountered by the ESF professionals. hus, to highlight these experiences two sub--categories were established.
In the sub-category “social vulnerabilities as a phe-nomenon that generates moral distress” the participants revealed that they often encountered situations of family conlicts related to domestic violence and adverse socio--economic issues.
“So these things, violence, psychological aggression, we have a lot of these in the ESF, but I can’t do anything! he patients have conidence in me; I think that if I remove this conidence that they have in me then the situation will worsen.”[...] If something ha-ppens to me, I’ll give you my sister’s phone number, will you call her? [...] But I don’t want you to make any oicial complaint [...]. “(ACS3)
“As my area deals with older patients I came across a case where a son assaulted his mother. Finally, I had to call to the social worker to go there because it was too much; I could no longer go there on my own.” (ACS 4)
Social vulnerabilities and the absence of an inter-sec-toral approach were cited as obstacles to decision-making.
“We know you there is legislation that guides what we do, but then we have to depend on other sectors that do not take appropriate action and we end up alone and have to resolve these situations. It often reaches a certain point where my knowledge is limi-ted and then there are situations where we are stuck because we don’t know how to reach a solution.” (E3)
“We know that we have to solve problems but someti-mes we are prevented by the patients themselves. What can health workers do? We have to respect the patient because otherwise they won’t let us visit their home again. So there are times when we don’t do anything and that is diicult because you are aware of the situa-tion but can’t do anything about it.” (ACS 3)
he sub-category “weaknesses of the health system and their relationship to experiences of moral distress” revealed experiences of MD by FHS professionals in connection with weaknesses in the health system.
“I had a patient who was four months old and she had respiratory failure. She was wheezing, whee-zing and the mother came and I didn’t have a mi-cro-nebulizer to use. So we sent her to the hospital and the hospital doctor took her and said, “she’s just groaning because she is a little bit tired, she just has a little pain in her body“[...]”And this was a little girl with respiratory problems !! here was nothing more that could be done there, you know? here was no other remedy, no inhaler [...] there was no pe-diatrician there either, which was a service that we had. We were only able to use the oicial car to take her to the hospital; the mother would have had to make her own way back. She preferred not to go be-cause she said “M3 how can I go there, how will I be able to get back?” (M2)
“he biggest problems are those that are inherent wi-thin the Uniied Health System (SUS), which is usu-ally the major limiting factor because of the scarcity of resources and delay in conducting tests, performing operations etc. So this ends up distressing patients and delaying diagnoses by professionals.” (M1)
“Sometimes there is lack of some material, such as di-sinfectant, and you end up acting inappropriately so as not to stop the service.”(E2)
“We see some cases that are not really for us. hey are referred to us from elsewhere but we can’t do the sa-me thing ... We often ind another diiculty as well, patients come back to us from where they started out, from their starting point, which is the basic health service.” (TE2)
Negative feelings, of helplessness and frustration, whi-ch were also associated with feelings of guilt, were also wi-dely cited by the health professionals.
“[...] I know what’s best, I know it would be easier for the patient as well, but I can’t do anything.” (M2)
“When we are trying to provide something that you know you is needed, that the person is in need of it right then, and that it’s not feasible, that really makes you anxious.” (E3)
“It gives you a sense of powerlessness, right? I can’t do anything, my hands are tied.”(M2)
DISCUSSION
Health care in Brazil has provided health care workers with experiences that they have never encountered before in hospitals and outpatient services. Within the ESF, pro-fessionals and service users are active individuals who share communal spaces and subjectivities. In intersubjective rela-tionships, links are established that outline new contours to interpersonal relationships.
In this regard, health care meetings are permeated by the subjectivity of individuals, their vulnerabilities and their methods of coping (16).
In this study, the participants brought with them their care experiences, which were shaped by the social vulnerabilities that service users were exposed to. Based on the content of the interviews, the authors inferred that the ACS’s were most exposed to this because most of them lived in the community where they worked. Consequently they were not only workers, but also nei-ghbors of the service users that that visited on a mon-thly basis.
ACS’s are perceived by the population and Family Health Teams as individuals who are essential to the con-solidation of the reorganization of the SUS. ACS’s belong to a community, in which they become a reference point, as well as being active professionals whose role is to mo-tivate the population in terms of social action and health care (17).
hus, such rapport represents a connotation that is re-lated to the representation that FHS professionals have in relation to individuals and activities related to health care. In this sense, a study of the Humanization Policy in PHC in Brazil (18) highlighted the work of interdisciplinary teams as an important tool for building relationships of trust and friendship based on rapport, which is bringing professio-nals closer to the reality experienced by service users.
However, this approach can contribute to the emer-gence of contradictions which are related to beliefs, values, ideals and ways of life, which conforms to the peculiarities of the ethical issues that occur in PHC (19).
Moral Distress in Family Health Strategy: experiences expressed by daily life proximity with the community and knowledge about pro-blems and situations related to social vulnerability; failure to set limits in relation to service users; proximity to fa-milies; and intimate knowledge about families and their “careless” health practices. All these indings were echoed in the present study.
It is worth stressing once again that MD can be un-derstood as a situation in which a professional recognizes their moral responsibility in the face of diicult situations and considers that there is a correct way to act, but due to institutional impediments or constraints they feel una-ble to make a correct decision; they consider their moral participation in the situation to be inadequate and may be afected by physical symptoms such as pain or distress that afects the body or the mind (9-10).
A study of domestic violence against women (21) sho-wed that ACS’s have the greatest proximity and rapport with service users and because of that they experience the problems and vicissitudes of their clients to a high degree. he aforementioned study prescribes the need for training for ACS’s and other professionals regarding gender issues, which relate to violence against women, thereby empowe-ring the guidelines of the SUS on this issue.
Regarding narratives that express weaknesses in the he-alth system, it is clear that problems connected with the organization of work involving structural issues in relation to the ESF, such as the lack of apparatus for urgent and emergency care; the lack of support from other sectors to discuss and solve identiied problems; and the shortage of equipment, medicines and transport hinder the quality of service and have ethical implications, both for professio-nals and for health service users: they also become a pree-minent source of MD (9-10).
he meta-synthesis developed in PHC (18) is consistent with the present study and it has highlighted the lack of equipment and material resources in health units as having a negative impact on continuity of care, as well as genera-ting unfavorable working conditions. Furthermore, it has identiied the lack of an eicient health care network as being a barrier to humanized care.
he participants in the present study revealed, both through their interviews and their narratives in relation to the concept of MD, the reality of a challenging professio-nal practice, in which expressing care in its most sublime form seems be paradoxical when the essence of actions designed to alleviate the sufering of others are hampered by anguish on the part of professionals, which is intrinsic to the work of health teams (10). From this perspective, a move towards reversing the silent experience of MD would reveal the problems and the ethical challenges that PHC professionals are exposed to.
Integrating Family Health Teams entails being respon-sible for the population of a deined area and monitoring that population over time, which implies challenges to pro-fessional ethical practices. Family Health Teams perform functions that go beyond the traditional response to health needs and they develop continuous, speciic and natural ac-tions based on the establishment of rapport, respect and
co-responsibility with the local population, all of which epitomize comprehensive health care.
herefore, when professionals perceive diiculties in dealing with situations that compromise an ethical ap-proach in the workplace this opens up the possibility of MD, which is manifested by an inconsistency between professional actions and personal convictions, resulting in psychological imbalances characterized by feelings of su-fering. In this scenario, professionals who experience situ-ations of MD and who feel helpless in the face of emerging problems can choose to change the location where they work as a strategy to preserve their values in a new work context (8).
he creation of spaces in which situations that provoke MD can be described and discussed is essential in health care centers. he involvement of coordination and leader-ship, especially with regard to issues related to human and material resources, can ensure a healthy and productive work environment (10).
he experience of studying real stories about the experience of ethical issues in daily working situations, and their implications for the individuals involved, ma-de it possible to relect on this topic, which is still little discussed in terms of health practices and actions. he reports of weaknesses in the health system showed that the professionals who participated in this study faced daily situations that contradicted their ethical precepts, which allowed for the greater possibility of the develo-pment of MD.
However, given the complexity of the issue under dis-cussion, this study steered clear of generalization, since the authors addressed the participants in order to know how they experienced MD. Consequently, further studies should be conducted from an interdisciplinary perspective so that other silent phenomena, which result in MD, can be revealed.
CONCLUSION
he results of this research show that the Family Heal-th Service workers who participated in Heal-this study experien-ced moral distress in their daily work. Social vulnerabilities, such as domestic violence and poor socio-economic condi-tions, in addition to the organizational weaknesses of the health system were the main triggers of this moral distress.
Such situations are not consistent with the principles of the Uniied Health System (SUS) and they denote an assault on individual and collective rights, as well as human dignity. Such situations therefore have implications for he-alth service professionals who, in this study, expressed fe-elings of helplessness and even guilt for failing to provide comprehensive assistance to service users.
RESUMO
Objetivo: Compreender as vivências de Sofrimento Moral expressas no cotidiano da Estratégia de Saúde da Família.
Método: Trata-se de um estudo de caso com abordagem qualitativa, realizado entre os meses de agosto a outubro de 2014, cujo cenário foi um município
de Minas Gerais. Participaram 28 proissionais das equipes de saúde da família. Os dados foram coletados por meio de entrevistas com roteiro semies-truturado, observação, técnica projetiva e, submetidos à análise de conteúdo temática.
Resultados: Os resultados apontaram que as questões rotineiras do serviço de saúde levam os proissionais a vivenciarem uma prática desaiadora ao
lidarem diariamente com situações que contradizem seus preceitos éticos capazes de comprometer a qualidade do trabalho tornando-se disparadores de Sofrimento Moral.
Conclusão: As vulnerabilidades sociais, como violência doméstica e condições socioeconômicas precárias, além das fragilidades organizacionais do
Sistema de Saúde, foram os principais geradores de Sofrimento Moral. Assim, considera-se necessária a relexão ampliada sobre a temática por parte dos trabalhadores da Estratégia de Saúde da Família, com intuito de propiciar a minimização de vivências de sofrimento e uma prática proissional em consonância com seus valores éticos.
DESCRITORES
Estratégia de Saúde da Família; Ética; Dano Moral.
RESUMEN
Objetivo: La comprensión de las experiencias de Sufrimiento Moral expresadas en la vida cotidiana de la Estrategia Salud de la Familia.
Método: Es un estudio de caso con un enfoque cualitativo, realizado entre agosto y octubre de 2014, cuyo escenario fue un municipio de Minas Gerais.
Con la asistencia de 28 profesionales de los equipos de salud de la familia. Los datos fueron recolectados a través de entrevistas con, la observación, la técnica semiestructurada proyectiva y sometidos a análisis de contenido temático.
Resultados: Los resultados mostraron que los problemas de servicio de salud de rutina conducen los profesionales experimentar una práctica difícil en el
trato diario con situaciones que contradicen sus preceptos éticos que pueden comprometer la calidad del trabajo por lo que es desencadena el sufrimiento moral.
Conclusión: Las vulnerabilidades sociales como la violencia doméstica y las malas condiciones socioeconómicas a través de los puntos débiles de la
organización del sistema de salud fueron los principales generadores de sufrimiento moral. Por lo tanto, considera que es necesario ampliar la relexión sobre el tema de los trabajadores del Estrategia Salud de la Familia, con el objetivo de fomentar la minimización de sufrir experiencias y la práctica profesional en consonancia con sus valores éticos.
DESCRIPTORES
Estrategia Salud de la Familia; Ética; Daño Moral.
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